Orthopaedic Outcomes Research Articles

Early Orthopaedic Trauma Outcomes in COVID-19 Infected Patients: A Case Series.

Orthopaedic trauma presents a unique and complex challenge in the initial phase of the coronavirus 2019 (COVID-19) global crisis. Little is currently known about the surgical practices in orthopaedic emergencies in the early days of the COVID-19 outbreak (1). This is a retrospective case series of 10 orthopaedic trauma patients who underwent fracture fixation in March 2020. Of the 10 patients testing COVID-19 positive, there were a total of 16 long bone fractures, 5 pelvic ring fractures, and 1 lumbar burst fracture. There were 7 (70%) males in this cohort. Two (20%) of the COVID-positive patients did not develop fever, leukocytosis, respiratory insufficiency, or positive imaging findings and were younger (average age 25.5 years) with fewer comorbidities (average 0.5) compared with the 8 symptomatic COVID-19-positive patients (56.6 years with 1.88 comorbidities). Advancement of COVID-19 pathogenesis with lung opacities and prolonged intubation occurred in all 5 patients who remained on ventilation postoperatively (range 9 hours-11 days). At the time of most recent follow-up, all patients survived, 1 continues to require ventilation support, 1 remains admitted without ventilation support, and 8 (80%) were discharged to home. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

On the question of osteomyelitis and its consequences in children: literature review

According to the literature data, the article considers the occurrence and development of acute and chronic osteomyelitis. The basic principles of classification and terminology are presented. The authors paid special attention to the features of the clinical manifestations of osteomyelitis and its spread, identified clinically important focal changes in osteomyelitis. The etiology, pathogenesis and features of pathophysiology with a different mechanism for the development of osteomyelitis are considered. The moments, affecting the formation of orthopedic outcomes in the form of deformations, shortening of limbs are noted. The authors examined the complications and tactical features in the treatment of the effects of osteomyelitis. The importance of a systematic approach to treatment, the determination of the stages and their contents, taking into account the main process and the anatomical and functional expediency, are accentuated.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery.

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

Automated surveillance of orthopaedic implants: a systematic review

Abstract Introduction More than 200,000 orthopaedic implants are implanted each year in France. Automating the data collection of device-related patient outcomes in orthopaedics is a challenge to improve device monitoring and though orthopaedic practices. The goal of this study was to assess the existing models of automated surveillance of medical devices in orthopaedics, by performing a systematic review. Methods The research equation contained the following MeSH terms from PubMed [Arthroplasty, Replacement], combined with [Patient Generated Health Data], [Public Reporting of Healthcare Data], [Medical Records Systems, Computerized], or [Data Warehousing]. Articles were extracted among peer-reviewed journal, in English. Titles and abstracts of selected articles were double-blind reviewed to include the articles in the study according to the following criteria: data obtained automatically, without duplicate data entry by caregivers or review of medical records one by one. For each study, we recorded: device location, targeted population, population size, methods and objectives. Results From the 54 articles identified through PubMed, 23 articles met the inclusion criteria after review of titles and abstracts 18 considered surveillance of knee devices and 13 hip devices. Monitoring of other joint prosthesis was practically absent. The aims of the analyses primarily concerned postoperative complications and length of stay, but the objectives were widely various. Discussion There were few studies using electronic medical records or clinical data warehouses to monitor devices in orthopaedics. The majority of the included studies were performed on claim databases. An information bias about data collection methods was frequently identified in the abstracts. The literature review highlighted the potential uses of health data in joint replacement and the current underuse of the medical records and/or data warehouse in orthopaedic surveillance. Key messages There were few studies using automated surveillance to monitor devices in orthopaedics. The aims of automated surveillance concerned postoperative complications and length of stay.

Motorized Intramedullary Lengthening Nails: Outcomes and Complications

The outcomes of motorized intramedullary lengthening nails are overwhelmingly good with acceptable complication rates and high surgeon satisfaction. While patients report overwhelming approval to surgeons, universal orthopedic outcomes scores fail to capture the true benefits of these procedures. Many studies have been cited in table format in this report. Pearls from experienced surgeons are reviewed and include the benefits of antegrade nailing over retrograde, prophylactic soft tissue release, and blocking screw use. Pitfalls are explored to keep the reader vigilant for mechanical failure of the nail, delayed healing, and common tibial difficulties. Through compiling data, estimates of collective complication incidence are presented.

A clinically friendly viscoelastic finite element analysis model of the mandible with Herbst appliance

As a powerful numerical approximation tool, finite element analysis (FEA) has been widely used to predict stress and strain distributions in facial bones generated by orthodontic appliances. Previous FEA models were constructed on the basis of a linear elastic phase of the bone response (eg, elastic bone strains to loading). However, what is more useful for clinical understanding would be predicting long-term strains and displacements of bone-segments responding to loading, yet tissue responses are (1) not promptly observable and (2) hard to predict in nature. Viscoelastic property of the mandibular bone was incorporated into FEA models to visualize long-term, time-dependent stress and strain patterns in the mandible after being exposed to orthopedic stress. A mandible under loading by a Herbst appliance was modeled, and outcomes of the constructed elastic and viscoelastic models were compared. Patterns and magnitudes of the displacement throughout the mandible predicted by the viscoelastic model were exhibited in accordance with previous clinical outcomes of Herbst appliance therapy. The elastic models exhibited similar displacement patterns; however, the magnitude of the displacements in the models was invariably small (approximately 1 per 100) compared with those outputs of corresponding viscoelastic models. The corresponding maximum stress level in our viscoelastic mandible subjected to the Herbst appliance with the same loading was considerably low and relaxed in various regions when compared with the elastic model. We suggest that a viscoelastic model of the mandible mimics our general prediction of orthopedic treatment outcomes better than those by elastic models.

Legg-Calve-Perthes disease in an 8-year old girl with Acrodysostosis type 1 on growth hormone therapy: case report

BackgroundAcrodyostosis type 1 (ACRDYS1) is a rare skeletal dysplasia, and sometimes it can be misdiagnosed as pseudohypoparathyroidism type 1A (PHP1A), a subtype of Albright hereditary osteodystrophy (AHO), due to overlapping features. Growth hormone releasing hormone (GHRH) resistance with severe short stature is common in both ACRDYS1 and PHP1A (Emily L. Germain-Lee, et al. J Clin Endocrinol Metab, 88:4059–4069, 2003). Whereas growth hormone (GH) treatment has been studied in patients with PHP1a, the same is not true for the rarer ACRDYS1. Here in we report an adverse orthopedic outcome in a patient with ACRDYS1 with severe short stature treated with growth hormone. Our experience could have implications for the treatment of other patients with this disorder.Case presentationWe report a case of Legg-Calve-Perthes Disease (LCPD) in an 8-year old female with ACRDYS1 treated with GH. She initially presented with marked short stature (height Z-score − 3.46) with a low normal insulin like growth factor-1 (IGF1) level, and had biochemical evidence of thyrotropin and parathyroid hormone resistance. GH therapy was initiated at 0.35 mg/kg/week leading to increased growth velocity. After 7 months on GH, she developed right knee pain. Radiographic images revealed flattening of her right femoral head consistent with LCPD. GH was discontinued. Six weeks later, radiographs revealed further collapse of the entire femoral head. Her lesion stabilized after 8 months with conservative management and she never resumed GH. Her final adult height is 4′2″ (128 cm).ConclusionPatients with ACRDYS1 on GH therapy may be at increased risk of LCPD. This has not been reported in patients with PHP1A treated with GH. Clinicians and families need to be aware of this potential complication when counseling about GH treatment.

Human perivascular stem cells prevent bone graft resorption in osteoporotic contexts by inhibiting osteoclast formation.

The vascular wall stores mesenchymal progenitor cells which are able to induce bone regeneration, via direct and paracrine mechanisms. Although much is known regarding perivascular cell regulation of osteoblasts, their regulation of osteoclasts, and by extension utility in states of high bone resorption, is not known. Here, human perivascular stem cells (PSCs) were used as a means to prevent autograft resorption in a gonadectomy‐induced osteoporotic spine fusion model. Furthermore, the paracrine regulation by PSCs of osteoclast formation was evaluated, using coculture, conditioned medium, and purified extracellular vesicles. Results showed that PSCs when mixed with autograft bone induce an increase in osteoblast:osteoclast ratio, promote bone matrix formation, and prevent bone graft resorption. The confluence of these factors resulted in high rates of fusion in an ovariectomized rat lumbar spine fusion model. Application of PSCs was superior across metrics to either the use of unpurified, culture‐defined adipose‐derived stromal cells or autograft bone alone. Under coculture conditions, PSCs negatively regulated osteoclast formation and did so via secreted, nonvesicular paracrine factors. Total RNA sequencing identified secreted factors overexpressed by PSCs which may explain their negative regulation of graft resorption. In summary, PSCs reduce osteoclast formation and prevent bone graft resorption in high turnover states such as gonadectomy‐induced osteoporosis.

The Effect of Depression on Patient Reported Outcomes Measurement and Information System Computer Adaptive Test (PROMIS-CAT) scores and Return-to-Sport following ACL Reconstruction

Objectives:Depression has been shown to have a negative effect on many orthopaedic surgical outcomes. The purpose of this study was to determine whether preoperative clinical diagnosis of depression and/or PROMIS (Patient-Reported Outcomes Measurement Information System) Depression scores predicted worse postoperative therapy compliance, functional outcomes, and return-to-sport after anterior cruciate ligament (ACL) reconstruction.Methods:A multi-surgeon series of consecutive patients who had undergone ACL reconstruction at a single institution between 1/4/16 and 7/19/16 were evaluated for inclusion. Patients who had completed preoperative PROMIS Depression (D), Physical Function (PF), and Pain Interference (PI) questionnaires were prospectively enrolled to complete minimum 2-year follow-up PROMIS and Return-to-Sport (ACL-RSI short-form) questionnaires. Chart review was conducted to determine depression diagnosis status, demographic data, and rehabilitation physical therapy (PT) compliance. PROMIS D score cutoff for mild depression was >52.5, based on previously established correlation to the validated Patient Health Questionnaire-9.Results:Ninety-five of 115 consecutive patients (81%) met inclusion criteria. Average follow-up was 34+/-1.9 months. Fourteen patients (15%) carried a clinical diagnosis of depression. Thirty-two (34%) had a preoperative PROMIS D score above the mild depression threshold; of those, 2 (2%) scored in the moderate depression range, and 3 (3%) scored in the severe depression range. Overall, the cohort (including depressed patients) showed improvement in PROMIS PF and PI scores postoperatively (p<0.001) (Table 1). Diagnosed depressed patients had a higher rate of PT non-compliance (30.8%±17.3% vs. 21.9%±12.6%; p=0.04) and lower postoperative physical function (50.8±7.7vs. 57.5±10.5; p=0.03), but no differences in post-operative PROMIS PI (50.8±6.9vs. 46.7±6.8; p=0.32), compared to patients without depression diagnosis. The percentage of missed therapy appointments showed a correlation with lower postoperative PROMIS PF scores (r=0.33, p=0.008) in our cohort. PROMIS depressed (PROMIS D>52.5) and undiagnosed depression patients (subgroup of preoperative PROMIS depressed without depression diagnosis) showed no difference in PT compliance or postoperative PROMIS PF or PI, compared to non-depressed patients (Table 2). Undiagnosed preoperative depressed patients (n=21/95 (22%)) also showed improvement in their depression scores postoperatively (mean PROMIS D = 57.4±5.0 preop vs. 44.5±6.6 postop; p<0.0001) (Figure 1) and 19/21 (90.5%) patients in this group showed resolution in their personal PROMIS D score to non-depressed range (p=.001). PROMIS depressed patients were less likely to participate in a sport (16/32 (50.0%) vs. 50/63 (79.3%); p=0.003), but PROMIS depressed athletes had no differences in return to sport rates (10/16 (63%) vs. 25/50 (50%); p=0.38) or responses to the ACL-RSI Short Form questionnaire (p>0.05 for all).Conclusion:Clinically diagnosed depression is predictive of worse rehabilitation therapy compliance and worse functional outcomes after ACL reconstruction surgery, but even depressed patients can be expected to show improvement. PROMIS Depression scores, particularly in those without a clinical diagnosis of depression, can be expected to resolve to non-depressed range after ACL reconstruction. Patients with depressed mood preoperatively but no depression diagnosis could be considered to have “situational depression” and can be reassured that depression will likely resolve after ACL reconstruction. Patients with depression diagnosis, however, should be counseled regarding tempered expectations after ACL reconstruction. Resources should be allocated to incorporate behavioral health counseling pre- and post-surgery in an attempt to maximize outcomes.

Predictors of Large Labral Tears: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study

Objectives:Labral tears are often described by either their location (superior, anterior, or posterior) or their size, commonly defined as degrees of labral involvement from 0° to 360°. Large tears are thought to include 270° or more of the labrum, which has been reported to include 3.3% to 6.5% of those undergoing shoulder instability surgery for labral pathology. Demographic or injury characteristics of those with large labral tears (>270°) has not been defined in the literature. The purpose of this study was to identify factors predictive of a large labral tear at the time of shoulder instability surgery.Methods:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Those with an isolated SLAP (superior labrum anterior to posterior) tear or a concomitant rotator cuff tear requiring repair were excluded. Demographic data, injury history, preoperative patient-reported outcome scores (PROs), imaging and intraoperative findings, and surgical procedures performed were recorded. The treating surgeon reported the size and location of labral pathology visualized at the time of surgery. Patients with greater than a 270° tear were defined as having a large labral tear. For categorical demographic variables, a chi-square test or Fisher’s Exact test was used, as appropriate based on cell counts. For continuous demographic variables, a two-sample t-test was performed. In order to build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm (Lambert et al. 2018) was used to add significant interaction effects iteratively until no more significant two-way interactions could be added to the model.Results:After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort with an average age of 24.7 years old (12 – 66 years old). The incidence of large tears was 4.6% with the average tear size being 141.9°, or 39.4%. Males accounted for significantly more of the large tears seen in the cohort (94.7%, p = 0.01). Racquet sports (p = 0.002), swimming (p = 0.02), softball (p = 0.05), skiing (p = 0.04), and golf (p = 0.04) were all found to be predictive of large labral tears as was a higher Western Ontario Shoulder Instability (WOSI) score (p = 0.01) (Table 1). Patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (p = 0.007). Age, race, history of dislocation, injury during sport, or previous shoulder surgery were not associated with having a larger tear.Conclusion:Patients with large labral tears are a small, but not insignificant, subset of patients undergoing shoulder instability surgery. Multiple factors were identified as being associated with large labral tears at the time of surgery including male sex, pre-operative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Surgeons treating patients with these risk factors should be prepared to encounter a large labral tear at the time of surgery. Further studies will evaluate the outcomes of this patient population.Table 1.Comparison of patient demographics and sport history between shoulder instability patients with large labral tears (>270°).Small Tears (<270°)Large Tears(>270°)PN1178 (95.4%)57 (4.6%)-Sex (F, M (%F))219,959 (81.4% M)3, 54 (94.7% M)0.01Age24.69.0265.9.70.13Injury During Sport836 (71.0%)42 (73.7%)0.74Racquet Sport46 (3.9%)7 (12.3%)0.002Swimming205 (17.4%)17 (29.8%)0.02Softball114 (9.7%)10 (17.5%)0.05Skiing206 (17.5%)16 (28.1%)0.04Golf225 (19.0%)17 (19.8%)0.04

Risk Factors for Intra-Articular Bone and Cartilage Lesions in Patients Undergoing Surgical Treatment for Posterior Instability

Objectives:Patients with posterior shoulder instability often present with significant differences in history of injury and complaints compared to anterior instability that can lead to challenges in diagnosis and treatment. These patients may have bone and cartilage lesions in addition to caspulolabral injuries, though the risk factors for these intra-articular lesions are unclear. The purpose of this study was to describe intraoperative incidence of glenohumeral bone and cartilage lesions in a cohort of patients undergoing primary posterior stabilization using data from a prospectively collected, multicenter shoulder instability cohort. We hypothesized that patients with traumatic posterior instability with greater number of instability events would have higher rate of bone and cartilage injuries compared to those without fewer instability episodes.Methods:Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort was utilized for this study. This is a multi-center study encompassing a prospective evaluation of patients ages 12 to 99 years of age undergoing primary surgical treatment for shoulder instability by 24 orthopedic surgeons at 11 sites in the United States. Demographic data and specifics regarding the patient’s instability history were recorded, including patient age, sex, body mass index (BMI), history of smoking, and Beighton score. The number of instability events was classified as 0, 1, 2 to 5, or more than 5. The duration of symptoms was classified as <1 month, 1-3 months, 4-6 months, 7-12 months, or greater than 1 year. The glenohumeral joint was evaluated by the treating surgeon at the time of surgical treatment for bone and cartilage injuries, and patients were classified as having a bone or cartilage lesion (BCL) if there was any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of number of instability events on the presence of BCLs was investigated using Fisher’s exact tests. Multivariate analysis using logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as p<0.05.Results:There were 271 patients identified for analysis. Bone and cartilage lesions were identified in 59 patients (21.8%) at the time of surgical treatment (Table 1). The most common lesion was a glenoid cartilage injury, which was identified in 28 patients (10.3%). Patients with BCLs were significantly older and had significantly higher BMI relative to patients without BCLs (Table 2). There was a significant difference between the number of instability events and the presence of BCLs (p = 0.035), with the highest rate observed in patients with 2-5 instability events (33.9%) (Figure 1). Through multivariate logistic regression modeling, increasing age (p=0.002), increasing BMI (p=0.012), and 2 to 5 reported instability events (p=0.001) were significant independent predictors of the presence of BCLs.Conclusion:Bone and cartilage lesions are seen significantly more frequently with increasing patient age, increasing BMI, and patients with 2-5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury.Table 1.Frequency of Bone and Cartilage Lesions Identified in Patients Undergoing Primary Surgery for Posterior InstabilityIntra-Articular Lesion N % Glenoid cartilage injury*2810.3%Humeral cartilage injury*207.4%Reverse Hill-Sachs165.9%Glenoid bone loss114.1%Bony Bankart83.0%Any bone or cartilage lesion5921.8%*Indicates Outerbridge Grade 3 or 4 lesionsTable 2.Comparison of Patients With and Without Bone and Cartilage Lesions No Bone/Cartilage Lesion (N = 212) Bone/Cartilage Lesion (N = 59) Mean or N Standard Deviation or % Mean or N Standard Deviation or % P Value Age (Years)22.87.726.19.60.025Body Mass Index (kg/)26.34.628.65.20.0014Male Sex (N)17381.6%5084.8%0.70Smoker (N)73.3%46.8%0.26Hyperlax (Beighton >4)5224.5%915.3%0.16Pre-Operative Kerlan-Jobe Score49.321.842.418.30.094Pre-Operative WOSI Score43.618.438.917.70.11Pre-Operative SAS13.04.514.14.20.13WOSI: Western Ontario Shoulder Instability; SAS: Shoulder Activity ScoreFigure 1.

Do BTB ACLR Knees have more MRI signs of PTOA than their Contralateral Normal Knee at 2 Years?

Objectives:The prevalence of patellofemoral joint (PFJ) osteoarthritis (OA) ranges from 8-47% 7-10 years after anterior cruciate ligament reconstructions (ACLR) using bone-patellar tendon-bone (BTB) autograft. In performing BTB ACLR, some hypothesize that either trauma caused by harvest of the patellar bone autograft or altered biomechanics lead to PFJ post traumatic osteoarthritis (PTOA). Our objective was to evaluate by 3T MRI whether the ACLR knees had more signs of early PTOA compared to the contralateral knee within the MOON nested cohort. We hypothesize that a BTB autograft harvested using a minimally traumatic technique will not increase the risk of PFJ OA.Methods:MRIs of operative and contralateral uninjured knees were collected in 60 patients (28 males, mean age 21 years) from a single site in the Multicenter Orthopaedic Outcomes Network (MOON) nested cohort at minimum 2 years post BTB ACLR. Harvesting the patellar block for the BTB autograft was performed using an oscillating saw with a narrow blade, being careful not to extend the cut into the posterior cortex of the patella, and with gentle elevation of the bone block with an osteotome. MRI was performed at 3T (Philips, Achieva) and the imaging protocol included intermediate-weighted sagittal turbo spin-echo (TSE) imaging, axial and coronal fat-saturated TSE imaging, and 3D coronal gradient echo imaging. Structural MRI assessment of the knees was performed using the MRI Osteoarthritis Knee Score (MOAKS) semi-quantitative scoring system by a board-certified musculoskeletal radiologist. The prevalence of cartilage defects in each knee compartment (medial, lateral, patellofemoral), meniscal tears (medial, lateral; yes/no), bone marrow edema-like lesions (BMEL; medial, lateral, patellofemoral; yes/no), effusion (yes/no) and Hoffa synovitis (yes/no) were compared between the reconstructed and contralateral uninjured knees. Hypothesis testing was performed for the PF joint using a logistic regression model where the dependent variable was presence/absence of cartilage loss and the independent variable was knee status (surgical or contralateral).Results:There were no significant differences in the prevalence of cartilage defects (any lesions or full thickness loss) in the PFJ between the surgical BTB ACLR knees and the uninjured non-operative contralateral control knees. 38.3% of BTB ACLR knees had PFJ cartilage defects versus 31.7% of contralateral control knees with PFJ cartilage defects (p>0.05) (Table 1). The BTB ACLR knees had more cartilage defects in the medial and lateral tibiofemoral compartments, more meniscal tears, BMEL, effusion and Hoffa synovitis, than the contralateral knees. Figure 1 shows examples of PFJ cartilage defects on MRI for the reconstructed and contralateral uninjured knees. At 2 years follow-up, KOOS symptoms, sports, pain, and activities of daily living scores were maintained at a high level ranging from 88-98.Conclusion:Although prior studies suggest BTB ACLR increases the risk of PFJ OA, the current study shows no difference in MRI signs of early PTOA in the PFJ. Cartilage defects comparing reconstructed vs. contralateral uninjured knees 2 years after surgery based on MRI were not different. These results should be used in shared decision making with athletes in choosing the appropriate autograft during reconstruction. Future studies will investigate the influence of cartilage defects found in the medial and lateral compartments further.

Defining the MCID, PASS and SCB for Arthroscopic Hip Preservation Surgery at Minimum Five-Year Follow-up

Objectives:Minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically significant outcome, however, it is unknown what represents meaningful patient reported outcome improvement in the medium to long-term. The purpose of the present study was to define MCID, PASS and SCB at a minimum five years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Secondarily, we sought to evaluate the time dependent nature of MCID, PASS and SCB.Methods:Patients undergoing hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score at 1-, 2-, and 5- years. MCID was calculated using a distribution-based method while PASS and SCB were calculated using an anchor method.Results:Two hundred and eighty-three patients were included with an average age of 34.2+11.9 years. The one year, two year and five-year MCID scores were as follows respectively: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4) and iHOT-12 (15.1, 13.9, 15.1). PASS scores were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6) and iHOT-12 (69.1, 72.2, 74.3). SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4) and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB and PASS at two-year follow-up than at one-year follow-up. However, 79.3% of the patients achieved MCID by 5 years.Conclusion:The greatest proportion of patients achieve clinically significant outcome improvement at two-year follow-up after arthroscopic treatment of FAIS. Improvements are maintained out to five-year follow-up although there is a slight decrease in the proportion of patients achieving clinical significance.Table 1.Frequency of patients achieving any MCID, PASS, or SCB threshold at 1,2, and 5-years 1-year 2-year 5-year p-value Any MCID233 (82.6%)247 (87.3%)224 (79.3%)0.035Any PASS191 (67.6%)211 (74.9%)191 (67.5%)0.114Any SCB176 (62.3%)190 (67.2%)160 (56.6%)0.034

Parkinson Disease Associated Differences in Elective Orthopedic Surgery Outcomes: A National Readmissions Database Analysis.

Background:Advances in the treatment of Parkinson’s disease (PD) have allowed for improvements in mortality and quality survival, making the management of comorbid conditions of aging, such as osteoarthritis, crucial.Objective:To determine the extent to which PD impacts hospitalization outcomes after an elective orthopedic procedure.Methods:This retrospective cohort study used data from the National Readmissions Database and included adults ages 40 and above with and without PD. Primary outcomes included length of stay of the index admission, discharge disposition and 30-day readmission. Logistic regression was used to compare the odds of readmission for PD patients compared to non-PD. Clinical conditions associated with readmission were compared between the two groups.Results:A total of 4,781 subjects with PD and 947,475 subjects without PD met inclusion criteria. Length of stay (LOS) during the index admission was longer for PD patients. PD patients were much more likely to be discharged to inpatient post-acute care (49.3% vs 26.2%) while non-PD subjects were more likely to be discharged home with (31.9% [PD] vs 44.8% [non-PD]) or without home health (18.7% [PD] vs 28.9% [non-PD]). A total of 271 PD patients (5.66%) and 28,079 non-PD patients (2.96%) were readmitted within 30 days following surgery. After adjusting for age, sex, socioeconomic status, expected payer, comorbidities, index admission LOS, year and discharge disposition, PD subjects were 31% more likely to be readmitted than non-PD subjects (AOR 1.31, 1.07–1.62).Conclusions:Parkinson’s disease patients were readmitted more often than non-PD patients, although the rate of readmission was still low.

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery.

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

Do Older Skiers Have Worse Outcomes After Anterior Cruciate Ligament Reconstruction Compared With Non-Skiers or Younger Skiers?

Background:There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations.Purpose:To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age.Study Design:Cohort study; Level of evidence, 3.Methods:A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student t tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes.Results:A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms (P = .01), KOOS Pain (P = .002), and KOOS Activities of Daily Living (P = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms (P = .02) and KOOS Quality of Life (QoL) (P = .01) subscales at 2 years and KOOS QoL (P = .01) at 6 years postoperatively compared with skiers 29 years or younger.Conclusion:Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR.

Patient Reported Outcome Measures in the Foot and Ankle: Normative Values Do Not Reflect 100% Full Function.

The primary purpose of this study was to determine normative values for foot and ankle ability measure (FAAM), activities of daily living (ADL), FAAM/foot and ankle disability (FADI) Sport, Tegner activity scale, SF-12 physical component summary (PCS) and mental component summary (MCS) in individuals who are representative of the "normal" adult population in the United States. The secondary purpose was to perform a confirmatory factor analysis (CFA) of ankle functional ability to provide evidence of reliability and validity of commonly used orthopaedic outcome scores. Our hypothesis was that normative values will differ based on patient characteristics and demographics, and that the selected commonly used foot and ankle outcomes scores will demonstrate acceptable reliability and validity estimates. There were 271 persons in this study (101 women, 170 men, average age = 31.4 (SD = 15.1) years, average BMI = 25.9 (SD = 5.9)). Age, sex and BMI were documented. Comparisons of outcome scores were made between cohorts. CFA was performed to test factor structure of ankle functional ability. There was no significant difference in FAAM ADL between women and men (n.s.) or FAAM Sport (n.s.). Women hadsignificantly higher SF-12 PCS (P = 0.001). Men had significantly higher SF-12 MCS (P < 0.001) and Tegner (P = 0.024). FAAM ADL, FAAM Sport and SF-12 PCS scores were significantly higher in people who did not have previous ankle surgery. Younger people and those with lower BMI had significantly higher ankle function. Reliability was excellent, and the CFA had excellent model fit demonstrating evidence of validity. This study revealed that normative values of foot and ankle outcome measures did not reflect 100% function and differed by sex, previous ankle surgery status, age and BMI. Individuals who did not have previous ankle surgery were younger, and had lower BMI and higher functional levels. Reliability was excellent, and the CFA model demonstrated excellent fit, providing evidence for validity, and lending support to use aggregated outcome measures as one scale. This study is unique in that it provides surgeons with normative ankle values in commonly reported outcome measures including the FAAM, FADI SF-12 and Tegner activity scale, in the normal population, based on BMI, age, gender and previous ankle surgery status. This information can be a very useful tool in the clinical setting for patient expectations counseling. In addition, surgeons and clinicians can feel confident using these outcome scores to assess their patients' progress through the continuum of care. Level II.

Hypoalbuminemia and obesity class II are reliable predictors of peri-prosthetic joint infection in patient undergoing elective total knee arthroplasty

BackgroundMalnutrition is a common and modifiable risk factor for postoperative complications and adverse outcomes in orthopedics. The purpose of this study was to identify biomarkers of malnutrition in patients undergoing elective total knee arthroplasty (TKA) that are predictive of adverse in-hospital postoperative complications, to facilitate the identification of at-risk patients for nutritional optimization before surgery.MethodsA total of 624 patients who underwent elective TKA between 2013 and 2017 were evaluated; potential biomarkers of preoperative malnutrition, including hypoalbuminemia (serum albumin < 3.5 g/dL), total lymphocyte count (TLC < 1500 cells/mm3), and body mass index (BMI), were assessed for any association with in-hospital postoperative complications.ResultsThe prevalence of hypoalbuminemia, low TLC, overweight, obesity class I, and obesity class II were, respectively 2.72%, 33.4%, 14.8%, 44.5%, and 26.9%. There was a significant association between hypoalbuminemia and obesity class II (BMI ≥ 30.0 kg/m2) with rates of peri-prosthetic joint infection, and no significant association between such complications and low TLC, overweight, or obesity class I. Logistic regression analysis showed that patients with hypoalbuminemia or being in obesity class II with gouty arthritis were more likely to suffer from peri-prosthetic joint infection.ConclusionsHypoalbuminemia and obesity class II together is a reliable biomarker of preoperative malnutrition for predicting peri-prosthetic joint infection after elective TKA, whereas low TLC, overweight, and obesity class I were not significantly associated with an increased risk of such complications.

Side-Effect Profiles And Efficacy Of Low Dose Intrathecal Morphine Combine With Periarticular Injection In Elective Primary Unilateral Total Knee Arthroplasty

Background:Total knee arthroplasty (TKA) is concerned as a severe postoperative pain procedure. Intrathecal morphine provides good analgesia but has many side effects such as nausea, vomiting, pruritus and respiratory depression. Appropriate postoperative pain control strategy with lower side effect is still challenging. We combined periarticular injection(PI) as a multimodal analgesia with intrathecal morphine in order to decrease intrathecal morphine dosage and lower side effects.Objective:To determine side-effect profiles and efficacy of 0.1 mg and 0.2 mg intrathecal morphine combine with PI in primary unilateral TKA.Material and method:In this prospective, double-blinded, randomized controlled trial. Patients undergoing TKA were recruited from April 2018 to April 2019. All patients were randomized into 3 groups. M 0 (n=32), M 1 (n=36)and M 2 (n=34) represent no intrathecal morphine, 0.1 mg and 0.2 mg intrathecal morphine respectively. All Group received same regimen of PI as a multimodal analgesia and same postoperative pain control protocol.Results:Patients in group M 2 had more nausea or vomiting side effects compared to group M 1 in early postoperative 4 hours(77.1% and 51.4%) with statistical significant(p<0.05) and also required 2 antiemetic drug to relieve symptoms (4.7% and 2.3%) with statistical significant ( p<0.05). No difference in postoperative pain score, rescue analgesic drug consumption ,pruritic score, sedation score, respiratory depression and orthopedic outcomes such as straight leg rising time and maximum active knee flexion between M 1 and M 2 groups.Conclusion:Lower intrathecal morphine dosage (0.1 mg) combine with periarticular injection in primary unilateral total knee arthroplasty provide similar postoperative pain control as standard intrathecal morphine dosage(0.2 mg) combine with periarticular injection with lower rates and severities of nausea and vomiting in first postoperative 4 hours.

A single dose of Bone Marrow Mononuclear Cells (BMMNCs) and Bone Marrow Plasma Concentrate (BMPC) for the treatment of Knee OA. 12 months of follow up

Background & Aim Osteoarthritis (OA) is a degenerative debilitating disease characterized by progressive erosion of the articular cartilage and is a major cause of disability and chronic pain. Articular cartilage, due to its structural features, has demonstrated a poor regenerative capacity after an injury. The intra-articular injection of the Bone Marrow Mononuclear Cells (BMMNCS) seems to be a safe manipulation for the treatment of Knee Osteoarthritis (Knee OA). Growth factors (plasma) derived from bone marrow aspirate concentrate (BMPC) seems to be potential for the treatment of the cartilage injured but there is no strong evidence of their use. Methods, Results & Conclusion Level I, prospective, descriptive study, between January 2018 and December 2019. 69 patients, range: 45-89 years, with knee OA Kellgren Lawrence (K-L) grade III and IV received one intra-articular injection of BMMNCs and BMPC in a same syringe (3ml) in a medium dose of 1.26 × 10 (9)/ml Mononuclear Cells and 704.000/ml Platelets. The main symptoms of knee osteoarthritis and tissue structure changes were evaluated after 12 months comparing the Visual Analogue Score (VAS) and Knee Injury and Orthopedic Outcome Score (KOOS) at different times. KOOS score was obtained at 3 months for 25 patients, 6 months for 12 patients and 12 months for 7 patients. The median KOOS score at the time “0 to 3 months” showed a statistically significant increase with respect to the initial moment (p <0.001) and a reduction to the moment “3 to 6 months” with respect to the previous moment that was not statistically significant (p = 0.313). Finally, the median of the KOOS returns to present a reduction at the last moment, “12 months”, with respect to “3 to 6 months” of similar magnitude to the previous reduction. The initial VAS value varied between 4 and 10 with the median being equal to 8.5 in the patients. In all cases, Global KOOS Score increase from the initial moment to the “0 to 3 months” was significant (p <0.001 for all subscales). No significant difference was found between the medians of the score at the “0 to 3 months” and “3 to 6 months” (symptoms: p = 1,000; stiffness: p = 0.423; pain: p = 0.313; functioning in daily activities: p = 0.313; functioning in sports and recreation activities: p = 0.125; quality of life: p = 1,000). The intraarticular implantation of a single dose of BMMNCs and BMPC for the treatment of Knee OA is a safe protocol and could improve quality of patient's life. In this study no adverse effects were seen. Osteoarthritis (OA) is a degenerative debilitating disease characterized by progressive erosion of the articular cartilage and is a major cause of disability and chronic pain. Articular cartilage, due to its structural features, has demonstrated a poor regenerative capacity after an injury. The intra-articular injection of the Bone Marrow Mononuclear Cells (BMMNCS) seems to be a safe manipulation for the treatment of Knee Osteoarthritis (Knee OA). Growth factors (plasma) derived from bone marrow aspirate concentrate (BMPC) seems to be potential for the treatment of the cartilage injured but there is no strong evidence of their use. Level I, prospective, descriptive study, between January 2018 and December 2019. 69 patients, range: 45-89 years, with knee OA Kellgren Lawrence (K-L) grade III and IV received one intra-articular injection of BMMNCs and BMPC in a same syringe (3ml) in a medium dose of 1.26 × 10 (9)/ml Mononuclear Cells and 704.000/ml Platelets. The main symptoms of knee osteoarthritis and tissue structure changes were evaluated after 12 months comparing the Visual Analogue Score (VAS) and Knee Injury and Orthopedic Outcome Score (KOOS) at different times.